When Hydronephrosis Was Not Physiological: A Case of Septic Shock Secondary to Obstructive Uropathy in Pregnancy

Urosepsis in pregnancy is a life-threatening condition requiring early recognition, rapid multidisciplinary escalation and timely source control.Physiological hydronephrosis is common during pregnancy and may obscure clinically significant urinary tract obstruction.We report a 26-year-old gravida 5 para 3 woman at 30 weeks' gestation who presented with severe right-sided loin pain.Initial ultrasound demonstrated moderate right hydronephrosis without a visible calculus.Within hours, she deteriorated with pyrexia, acute kidney injury, lactic acidosis and septic shock.Computed tomography demonstrated high-grade obstruction of the right renal collecting system secondary to a ureteropelvic junction calculus with associated inflammatory change.Following maternal deterioration and evidence of foetal compromise, an urgent multidisciplinary decision was made to proceed with category 1 caesarean delivery followed by cystoscopy and right ureteric stent insertion.Cultures grew Klebsiella pneumoniae.The patient subsequently required intensive care support including invasive ventilation, vasopressors, renal replacement therapy and treatment for disseminated intravascular coagulation.Both maternal and neonatal outcomes were favourable.This case highlights the diagnostic challenge of distinguishing physiological hydronephrosis from pathological obstruction in pregnancy and emphasises the importance of source control in infected obstructive uropathy.